Vision loss Rehab

Health Care Professionals Referral Form

Thank you for choosing to refer your patient to Vision Loss Rehabilitation Ontario for assistance with their vision loss. Once we receive your submission, we will reach out to your patient to develop their rehabilitation plan. If you prefer, you can download and complete an accessible version of the Health Care Professionals Referral Form (PDF) and send it by fax to 416-480-7700.

We encourage you to complete all fields on this form in order for us to formulate the best possible plan for your patient. However, if you are unable to complete all fields, we can follow up with you to get further information.

Only those fields marked with an asterisk (*) are required.

Please email us at info@vlrehab.ca should you have a problem submitting this form.

Patient information

Date of most recent eye examination (YYYY-MM-DD)

*Patient's date of birth (YYYY-MM-DD)

*Patient's first name

*Patient's last name

*Patient's street address

*Patient's city

*Patient's province or territory

*Patient's postal code

*CNIB office closest to patient

*Patient's phone number

Patient's provincial health card number

Alternate contact name

Phone number of alternate contact name

*Patient has consented to the release of this information to CNIB.

Date consent given (YYYY-MM-DD)

Name of person giving consent (if different from patient)

Patient's vision information

Distance VA (best corrected).

OD (right eye)

Other

OS (left eye)

Other

OU (both eyes)

Other

Near VA (best corrected).
OD (right eye)

Other

OS (left eye)

Other

OU (both eyes)

Other

Rx OD (right eye)

Add

Rx OS (left eye)

Add

Current correction is the same as the Rx for both OD and OS

Current Correction - OD (right eye)

Add

Current Correction - OS (left eye)

Add

Visual field

Describe field loss - OD (right eye) Visual field in degrees

Field loss description

Describe field loss - OS (left eye) Visual field in degrees

Field loss description

Primary cause of vision loss
OD (right eye)

Other

OS (left eye)

Other

Secondary cause of vision loss
OD (right eye)

Other

OS (left eye)

Other

*Primary functional reason for referral (e.g., patient struggles to read print)

Other medical conditions or limitations (e.g. arthritis, diabetes)

Referrer information

*I am an:

Ophthalmologist

Optometrist

Other health care professional

*Please specify health care profession

*First name

*Last name

*Clinic or office street address

*City

*Province or Territory

*Postal code

Doctor's license to practice number

*Phone

Fax

*Please fill in all mandatory fields before hitting submit.

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Patient information

Patient's vision information

Referrer information

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Health Care Professionals Referral Form